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v y ,Appiications Will Be Processed When Submitted Properly Camplet� e1 cation._fARAMF <br /> ICE USE: APPLICATI �l <br /> (For Non-Transferable, Revocabl , pe ble) PUMP&WALL <br /> ENVIRONMEPEn <br /> H <br /> (COMPLETE IN TRIPLICATE) _V'�f G '<< Q L T <br /> Application is hereby made to the SanJ� oaquinCocaHealth District for apermit toconstructr ? ipr rtlA `Idescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulaWEA6ui n Joaquin Local Health District. <br /> Exact Site Address_i Ill E. of Duncan Rd. & 50' S. of City/Town Linden <br /> Owner's Name T 'i r'Id en Circ ha rd s Comstock <br /> Phone <br /> Address City <br /> Contractor's Name s r+ +ng tlf< . License# 3792 Business Phone.__..8�7--3 5 54 <br /> Contractor's Address P.0- Rn-g 64 Emergency Phone 887-3948 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Id' V\ <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines i Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pits. Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑fJOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> e IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ' <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ,❑ State Work Done <br /> PUMP REPAIR: W 5' tate Work Done — Change Bowls '_ <br /> DESTRUCTION OF WELL: Well Diameter at a. Approximate Depth <br /> Describe Material and Procedure ' <br /> I hereby certify that I have prepared this application and that the work wili be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in toeiperformance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for r spection prior to grouting and a final insp ' n. <br /> Signed X Title: lr� Date: //17leO .._ <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPA TMENT USE ONLY 1 <br /> PHASE I <br /> Application Accepted By 2 Date v <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase II Final Inspection <br /> Inspection By Date Inspection By 4e 4DalFee Is Due: 11ANNUALLY ElPER UNIT 11PER SITE CIEACH ❑ January 1 &Received B n a 31 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE i ; $ <br /> BASE EXPLANAT#pN DATE DATE � ° REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `7Y2 a �s 3 <br /> Received by Date Receipt No. Permit No. l4uanh6 Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />